A Podcast Discussion With Marshall Glesby, M.D., Ph.D., and Jens Lundgren, M.D.
Caring for a Patient at High Risk
Marshall Glesby: Well, I'd just like to throw out the caveat that the example that you were giving did not appear to be somebody at high risk. If you had a patient at intermediate or particularly at high risk, then cardiovascular risk issues would be perhaps more important -- at least in my thinking about how to manage that patient.
Jens Lundgren: Absolutely.
Myles Helfand: So you might consider slicing the abacavir out, if abacavir were something that you were considering, if the person already had a high underlying risk of cardiovascular disease. But not otherwise.
Jens Lundgren: That would be my thinking. Again, the alternative to abacavir, if we are talking about that, is tenofovir. And you want to make sure that his kidneys are all right, as well. So you need to keep balanced views on things.
Myles Helfand: That's a really important point: I realize we're focusing very intently on cardiovascular complications, because that's the focus of this discussion. But this should not be done in a vacuum. As both of you mentioned earlier in this talk, there are a number of other complications that can potentially impact people with HIV, and they all need to be taken into account.
Marshall Glesby: I agree.
Final Thoughts for the Treating HIV Clinician
Myles Helfand: This is the part of it that feels stressful to me, if I were to be in a position to make those decisions. It feels like, particularly over the past several years, we have moved from a situation where treating an HIV-infected patient is mostly about just treating the HIV, to [a situation in which] treating an HIV-infected patient, depending on their CD4 count and viral load, is perhaps as much, if not even more, an issue of treating a lot of potential other comorbities that can come into play, and trying to balance the treatment of those, or the prevention of those, with the need to tackle the HIV infection itself. That's a pretty tall order for a lot of HIV clinicians, I would expect. Especially those who have traditionally been just very focused on infectious diseases.
Jens Lundgren: I agree that there's been a switch in the discussion around these things. But I think the underlying theme here is that HIV is bad for you and therefore if you are in need of treatment, you really need the treatment firsthand. And clearly, we have been discussing these other comorbidities more intensely, and we need to deal with them, and deal with them in a graded way, depending on people's underlying risk.
But it hasn't dramatically changed in the last two years; it's just been the focus of discussion. Which is healthy, because that just shows that we are now entering into a stage of managing HIV where we have become a little bit more sophisticated. So it's not only a CD4 and viral load discussion; it's also these other factors.
But, hey; that's not different from the rest of the population, where you need to deal with these issues, as well. So for me that's just a signal that HIV is becoming a normalized condition, where we need to focus on other issues, as well. And that's true for HIV patients, as well as the general population.
Marshall Glesby: I think those of us who are, let's say, infectious disease specialists do have to hone our general internal medicine skills so that we can manage some of these other issues, whether it's lipids or diabetes, etc., just to deal with the overall health status of our patients, rather than just focusing only on the HIV.
Jens Lundgren: And you know, sometimes HIV physicians have completely forgotten their internal medicine training. But what they learned in medical school is still valid. And if they aren't sure about it -- and I want to stress that -- if they aren't sure about it, and have been focusing on infectious disease and have lost some of the cutting-edge knowledge in other specialties, consult with some of your colleagues that are specialists in this. And make sure that you know how to mend these things in 2010.
There's nothing wrong with just admitting, "Well, I'm very good in antiviral therapy, but I don't have my skill set in cardiovascular disease prevention up-to-date." So talk to your cardiologist colleagues and ask them, "What would you do in this situation?" And they will tell you.
Myles Helfand: That seems like a pretty strong note to end on. Unless either of you have anything you'd like to add, I think we'll wrap it up here. Dr. Glesby, Dr. Lundgren, thank you both so much.
This transcript has been lightly edited for clarity.
Myles Helfand is the editorial director of TheBody.com and TheBodyPRO.com.
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